The 2001 American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements (referred hereafter as the Code) articulates clear values and goals of nursing practice. The directives outline our duties to care, advocate and be faithful to those who entrust their health care to us. The duty of the nurse to the patient and the patient’s environment are probably the best known to both nurses and the public.

As the industry of health care continues its transformation and evolution, we may need to emphasize other elements of our ethical code. The ANA Code (2001) also identifies, for example, the obligation of the nurse to work with other health professions, citizens and communities to promote the public’s health on both a local and national level "through individual and collective action" (p. 20).

In this column, the past triumphs gained by collective bargaining and the erosions of those triumphs are discussed,. This is followed by a historical look at changes in the health industry’s power based on economic changes. Then leadership opportunities that are grounded in ethics are discussed. Last, four calls to action are made that are based on Provisions six through nine of the Code.

Triumphs and Erosions

Past Triumphs

In 1946 the American Nurses Association’s House of Delegates unanimously approved a resolution that formally initiated the journey of registered nurses down the road of collective bargaining. This resolution called upon the State Nurses Associations to work actively to secure the general and economic welfare of its members. Since that time nurses have had an expanding right and freedom to organize and bargain as units with employers. Although the initial journey began with limited rights, these rights have been expanded in the past 50 years. In 1974, the National Labor Relations Act brought the rights and protections of federal law to non-supervisory employees of all health care facilities (Ketter, 1997). Budd, Warren, and Patton (2004) recently reviewed some of the outcomes of the expansion of these protections and rights. They found that many State Nurses Associations had successfully negotiated for salary and benefit increases, overtime and shift differential pay, shortened work hours, formal grievance procedures and some strategies to improve the patient care environment.

The Joy of Triumph Dissolves with Time

I recently asked a group of practicing registered nurses to comment on their thoughts and experiences with collective bargaining and striking. An intense conversation among these nurses followed. Two themes dominated the conversation. The first theme was the profound commitment of these nurses to their ethical duty to provide quality care to the patients. The second theme was the personal, internal conflict, distress, and tension with the collective bargaining experience.

One of the most interesting aspects of this discussion was that regardless of the outcome, collective bargaining was not described with any sense of joy, triumph, or as a satisfying experience for any of these nurses. The nurses who had the experience of living through a collective bargaining process that threatened or resulted in an actual work stoppage described a period that was ripe with animosity, mistrust and lingering concerns about abandonment of their duty to provide care. Others in the group spoke of the experience of crossing the picket lines and being subjected to harassment and verbal abuse by their colleagues. Both groups of nurses found themselves pitted against not only management but also against other nurses.

The nurses in this discussion did not seem to understand the basic underlying construct of traditional collective bargaining. It is an adversarial process. The basic goal is to win something that is presumably controlled by another. The weapon is the power of numbers. In the case of nurses, there is the overt or covert threat to economically disrupt the health care facility. Simply put, the goal is to win by defeating the opponent.

The Impact of History

In past decades traditional collective bargaining held promise and assisted the professional nurse’s evolution towards robust power within the health care industry. However, the power and potency of nursing as an industry leader has been mitigated by history. This historical evolution may provide a glimpse into the dissatisfaction of today’s nurses with their experience with traditional collective bargaining. More importantly, it may provide a key held within the ANA Code (2001) that has the potential to catapult nurses to capture the exhilaration that occurs with effective leadership and creative problem solving for a health system that is plagued with problems.

Forty years ago managed care had not really begun its evolution. Instead, health services were provided in what could be compared to a retail transaction. Patients went to the physician providers of their choice and received care in the hospitals that they and their doctors elected. The patients’ employers, through their group insurance policy, reimbursed a designated percent of the charges for services and procedures during the hospital stay. The supplier charges were calculated upon the cost of each aspect or procedure performed during an episode of care, and oversight was minimal. The more the provider did to or for the patient, the higher the charge and the greater the potential for incoming revenue. In the light of this type of basic commercial transaction, health care institutions had the potential to acquire and maintain a healthy financial position. The nurse’s role in this commercial enterprise was primarily limited to the duties of the nurse in direct patient care. Although those duties continue to exist, the role of the nurse has and continues to expand.

Today managed care is a broad term that may be thought of as an active link between the financing of health care services and their delivery (Copeland, Brzytwa, Blixen, & Hewson, 2003). Reimbursement or payment is not based on the provision of discrete procedures or services. It is a set rate that is negotiated with the federal and private insurers. The rate is based on the admitting diagnosis and the expected number of days the patient spends in a health care facility. The retail commerce of health care has essentially disappeared. The pressure of the spiraling price tag of care that neither federal programs nor employers could any longer afford brought a close to retail health care.

The intensity or the amount of incidental care that arises during a hospital stay does not play a significant role in the reimbursement equation (Stewart, 2003). With this type of payment arrangement, health care has become an industry struggling for fiscal solvency. The basic commercial transaction and fiscal strength of health care organizations that existed during the journey of nurses as members of traditional collective bargaining units has died.

In 2000, the American Hospital Association reported that nearly a third of the nation’s hospitals were operating in the red. This is grim, but not nearly as grim as when one realizes that in some areas of the country over half the hospitals are deficit operations (Stewart, 2003). However, the potential of nursing to provide solutions to an industry under siege has never been greater.

Opportunities for Leadership Grounded in Ethics

The nurses’ descriptions of collective bargaining and the historical change in reimbursement, when considered in light of the ANA Code (2001), provide clues to the angst associated with collective bargaining. More than half the provisions of the Code are rich with implications for caring, respectful, collaborative, and creative behaviors that extend beyond the isolated relationships among the nurse, patient, and employer. Although collective action and advocacy are noted in the 2001 Code, the participation in an adversarial process of traditional labor relationships is not part of its primary fabric. If one considers the Code as an essential element of the collective consciousness of the discipline of nursing, one senses a rich intellectual and practice texture that provides the foundation for a synergy of collaboration with others to creatively solve problems arising in a complex industry.

Consider for a moment that the largest and most educated professional group in the health care industry is nursing--a group with a tradition steeped in values and an ethical code that presses the nurse to consider the value of the human as patient, as community member and as fellow health professional. These assets may hold the critical edge for nurses as collaborative problem solvers, solution strategists and leaders for a health care system.

There are several basic assumptions that nurses will need to adopt, if we are to effectively step away from the adversarial process of traditional collective bargaining into effective leadership roles. One approach that is coming into focus is referred to as Interest Based Bargaining (IBB) (Brommer, Buckingham, & Loeffler, 2003). This is a non-traditional style of bargaining that attempts to problem solve differences between labor and industry. Although this style of bargaining and mediation will not always eliminate the need for the more traditional and adversarial collective bargaining, this non-adversarial approach of negotiation may be closer to the basic fabric of the discipline of nursing and its ethical code. IBB is a process that requires health care disciplines to understand the interests and outcomes that are important to the other members of the industry. Once this understanding is achieved, a creative dialogue for the accomplishment of these interests can begin to evolve (Budd et al., 2004).

It is proposed here that before understanding the views of others, it is a required initial step to reexamine one’s views. One avenue for examining nursing’s views is through reflection on the ANA Code (2001), since the purpose of the Code is to outline the aims, principles, and responsibility of the profession. If one believes that "…ethical practice must be the foundation we hold constant in nursing" ( Ludwick & Silva, 1999, para 1), then the Code is the logical place to start.

The basic premise of the ANA Code (2001) is the nurse’s duty to the patient, and the first three provisions speak strongly to this premise. The second three provisions, as stated in the Code, address the nurse’s duties to self and to the practice and professional community. The last three provisions speak to the broader obligations beyond care. While all of the provisions must be understood for nurses to fully appreciate their own practice, provisions six though nine provide a framework that is particularly helpful to understanding collective bargaining from an ethical framework.

It is apparent much of the ANA Code (2001) is focused on care. This focus on care has led some nurses to be less prepared to understand issues (e.g., finances and policy) and processes like conflict resolution. When we lack understanding of these fundamental issues, it is almost unavoidable to lapse into a vision of oneself and one’s colleagues as powerless victims in a senseless system. Therefore, based on the last four provisions of the Code, I call all nurses to consider the following actions.

Calls to Action

Call for Action: Number One

Nurses are creative and powerful problem solvers who have much to offer systems that are confronted with the need to improve the quality and cost effectiveness of the process of care delivery. They need to recognize the power that they have to observe, identify, and improve the processes within the health care system.

Call for Action: Number Two

Health care and hospital administrators are not the enemy. They are health professionals. They too have professional codes of ethics. Their obligations and duties are different from those of the nurse, but are no less important. Nurses and administrators need to become familiar and respectful of one another’s ethical and professional obligations.

Call for Action: Number Three

Nurses are often lacking in their understanding of challenges of a hospital’s fiscal position. The finance and industry issues of health care have a very small role in the educational preparation of the nurse (Copeland et al., 2003) . This gap in the educational curriculum serves to limit the nurse’s active role in identifying care process problems and providing viable solutions.

As an alumna of an institution that provided your basic nursing education, you have power. Insist that any basic curriculum pay close attention to the business of health care delivery. Educators have an obligation to provide graduates with a working understanding of all aspects of the ANA Code (2001), especially provision six, which addresses collective action and advocacy.

Call for Action: Number Four

As nurses identify leaders and spokespersons for their groups, care should be taken to identify those persons who are able to listen, understand and communicate the interests and problems identified by the other parties at the negotiating table. These leaders need to be able to communicate the interests and problems encountered by other health care leaders back to nursing. The ability to articulate the nursing position alone does not suffice. It will limit the rise of the powerful and creative leadership that is nested in the heart and mind of each individual nurse.

Concluding Thought: Laborer or Leader?

Nurses should take pride in the richness of the 2001 ANA Code. It continues to cement our relationship and obligations to patients. It continues to identify our obligation to collaborate and respect the members of our own discipline and other health care disciplines. Additionally, it propels us to advance our journey to participate and lead in finding solutions to problems that face our local, regional and global health system.

To step up to the challenges of the provisions of our ethical code, we will need to understand the interests of all involved in the health delivery system. We need to take on the responsibilities to share, lead and become accountable for the evolution of a health system that provides safety, dignity, and care to both our local communities and our global neighbors.

One of the first steps required to make this ascent to live the Code is to broaden and enrich our understanding of the complexity of our industry. This means that we need to strengthen our ability to understand the issues that are outside the traditional province of the care of the individual patient and our own interests. We need to begin to see ourselves as owners of health system problems. These problems are large and require the synergistic collaboration of many to solve.

The evolution of health care, collective bargaining, and the ANA Code (2001) for Nurses presents us with new areas to consider and question. I will close this column with two questions: Is it in our best interest, the interest of the health care system, and the interest of those we serve to continue a traditional approach to collective bargaining? Will we not be better positioned to lead if we sit at the table with the mindset of leadership, partnership, collaboration, and collective problem ownership of the challenges facing the industry?

Dr. Kathleen Williams received her PhD in nursing from George Mason University in Fairfax, VA. Her current position on the Kent State University faculty focuses on acute and long term health care delivery. Prior to joining the academic community, Dr. Williams gained a broad range of experiences within various health care systems. She has served as an administrator concerned with creativity and cost effective service delivery, a staff nurse, a nursing assistant, a dietary aide, and a dishwasher. These experiences have provoked Dr. Williams to take note of and puzzle over many complex aspects of labor, leadership, and ethics within the health care delivery system.